Chapter 40: Fluid, Electrolyte, and Acid-Base Balance

The student nurse asks, "What is interstitial fluid?" What is the appropriate nursing response? • "Fluid inside cells." • "Fluid in the tissue space between and around cells." • "Watery plasma, or serum, portion of blood." • "Fluid outside cells."

Correct response: • "Fluid in the tissue space between and around cells." Explanation: Intracellular fluid (fluid inside cells) represents the greatest proportion of water in the body. The remaining body fluid is extracellular fluid (fluid outside cells). Extracellular fluid is further subdivided into interstitial fluid (fluid in the tissue space between and around cells) and intravascular fluid (the watery plasma, or serum, portion of blood).

A client has been diagnosed with a gastrointestinal bleed and the health care provider has ordered a transfusion. At what rate should the nurse administer the client's packed red blood cells? • As fast as the client can tolerate • 200 mL/hr • 75 mL/hr for the first 15 minutes, then 200 mL/hr • 1 unit over 2 to 3 hours, no longer than 4 hours

Correct response: • 1 unit over 2 to 3 hours, no longer than 4 hours Explanation: Packed red blood cells are administered 1 unit over 2 to 3 hours for no longer than 4 hours.

• The nurse is caring for a client whose blood type is A negative. Which donor blood type does the nurse confirm as compatible for this client? • AB negative • A positive • O negative • B positive

Correct response: • O negative Explanation: Type O blood is considered the universal donor because it lacks both A and B blood group markers on its cell membrane. Therefore, type O blood can be given to anyone because it will not trigger an incompatibility reaction when given to recipients with other blood types. Rh-negative persons should never receive Rh-positive blood

A physician orders an infusion of 250 mL of NS in 100 minutes. The set is 20 gtt/mL. What is the flow rate? • 30 gtt/min • 50 gtt/min • 20 gtt/min • 40 gtt/min

Correct response: • 50 gtt/min Explanation: The flow rate (gtt/min) equals the volume (mL) times the drop factor (gtt/mL) divided by the time in minutes.

Which nursing diagnosis would the nurse make based on the effects of fluid and electrolyte imbalance on human functioning? • Pain related to surgical incision • Risk for Infection related to inadequate personal hygiene • Constipation related to immobility • Acute Confusion related to cerebral edema

Correct response: • Acute Confusion related to cerebral edema Explanation: Edema in and around the brain increases intracranial pressure, leading to the likelihood of confusion. Constipation related to immobility, Pain related to surgical incision, Risk for Infection related to inadequate personal hygiene are nursing diagnoses that have no connection to fluid and electrolyte imbalance.

A nurse is reviewing the dietary intake of a client prescribed a potassium-sparing diuretic. The client tells the nurse that he had a banana, yogurt, and bran cereal for breakfast and a turkey sandwich with a glass of milk for lunch. The intake of which food would be a cause for concern? • Yogurt • Turkey • Milk • Banana

Correct response: • Banana Explanation: Bananas are high in potassium and would place the client receiving a potassium-sparing diuretic at risk for increased potassium levels. Milk and yogurt are good sources of calcium and phosphorus and would not be a concern. Turkey provides protein and would not be problematic.

The nurse is caring for a male client who has a diagnosis of heart failure. Today's laboratory results show a serum potassium of 3.2 mEq/L (3,2 mmol/L). For what complications should the nurse be aware, related to the potassium level? • Pulmonary embolus • Cardiac dysrhythmias • Fluid volume excess • Tetany

Correct response: • Cardiac dysrhythmias Explanation: Typical signs of hypokalemia include muscle weakness and leg cramps, fatigue, paresthesias, and dysrhythmias. Pulmonary emboli and fluid volume excess are not related to a low potassium level. Tetany can be a result of low calcium or high phosphorus but is not related to potassium levels.

The nurse is providing care for a client with a peripheral intravenous catheter in situ. What intervention should the nurse implement in the care of this IV? • Insert the largest gauge possible to maximize flow and minimize the risk of occlusion. • Clean the insertion site daily using sterile technique. • Flush the catheter every six hours with hypertonic solution if the IV is not in constant use. • Change the site every three to four days.

Correct response: • Change the site every three to four days. Explanation: Peripheral IV sites should be rotated every 72 to 96 hours, depending on the institutional protocol. IV insertion sites are not cleansed daily, but the site should be assessed per institutional protocol or every nursing shift. Flushes are not necessary every six hours. Hypertonic solution is not used for IV flushes. The smallest gauge that is practical should be inserted in order to minimize trauma.

A nurse inspecting a client's IV site notices redness and swelling at the site. What would be the most appropriate nursing intervention for this situation? • Discontinue the IV and relocate it to another site. • Call the primary care provider to see whether anti-inflammatory drugs should be administered. • Cleanse the site with chlorhexidine solution using a circular motion and continue to monitor the site every 15 minutes for 6 hours before removing the IV • Stop the infusion, cleanse the site with alcohol, and apply transparent polyurethane dressing over the entry site.

Correct response: • Discontinue the IV and relocate it to another site. Explanation: The nurse should inspect the IV site for the presence of phlebitis (inflammation), infection, or infiltration and discontinue and relocate the IV if any of these signs are noted. Cleansing will not resolve this common complication of therapy.

A nurse assessing the IV site of a client observes swelling and pallor around the site and notes a significant decrease in the flow rate. The client complains of coldness around the infusion site. What is the nurse's most appropriate action? • Slow the rate of infusion by 50%. • Attempt to aspirate. • Discontinue the IV. • Flush with 3-mL normal saline.

Correct response: • Discontinue the IV. Explanation: Infiltration is the escape of fluid into the subcutaneous tissue due to a dislodged needle that has penetrated a vessel wall. Signs and symptoms include swelling, pallor, coldness, or pain around the infusion site and a significant decrease in the flow rate. Likely, the IV needs to be discontinued if there is a combination of swelling and pallor. Aspiration is never performed from a peripheral IV. Flushing or slowing the infusion will not alleviate this problem.

A nurse is caring for four different pediatric clients, all of whom require insertion of an intravenous (IV) catheter. For which client would it be appropriate to insert the IV into the foot? • Infant • School-aged child • Preschool-aged child • Toddler

Correct response: • Infant Explanation: The foot is a potential IV insertion site for neonates and infants, but it should not be used once a child can walk.

• A nurse is caring for a client who has recently suffered burns on 30% of his body. Based on his condition, what type of IV solution might be ordered for this client? • 5% dextrose in 0.9% NaCl • Lactated Ringer's • 5% dextrose in 0.45% NaCl • 0.9% NaCl (normal saline)

Correct response: • Lactated Ringer's Explanation: Lactated Ringer's solution is a roughly isotonic solution that contains multiple electrolytes in about the same concentrations as found in plasma (note that this solution is lacking in Mg2+ and PO43- ). It is used in the treatment of hypovolemia, burns, and fluid lost as bile or diarrhea and in treating mild metabolic acidosis.

• A nurse monitoring a client's IV infusion auscultates the client's lung sounds and detects crackles in the bases in lungs that were previously clear. What would be the most appropriate intervention in this situation? • Place the client in the Trendelenburg position to keep the client's airway open. • Notify the primary care provider immediately for possible fluid overload. • Notify the primary care provider immediately because these are signs of speed shock. • Check all clamps on the tubing and check tubing for any kinking.

Correct response: • Notify the primary care provider immediately for possible fluid overload. Explanation: If the client's lung sounds were previously clear, but now some crackles in the bases are auscultated: Notify the primary care provider immediately because the client may be exhibiting signs of fluid overload. The Trendelenburg position is not used to rectify this complication, but to help raise the blood pressure of a client with hypotension.

A client's most recent blood work indicates a K+ level of 7.2 mEq/L (7.2 mmol/L), a finding that constitutes hyperkalemia. For what signs and symptoms should the nurse vigilantly monitor? • muscle weakness • cardiac irregularities • increased intracranial pressure (ICP) • metabolic acidosis

Correct response: • cardiac irregularities Explanation: Hyperkalemia compromises the normal functioning of the sodium-potassium pump and action potentials. The most serious consequence of this alteration in homeostasis is the risk for potentially fatal cardiac dysrhythmias. Muscle weakness is associated with low magnesium or high phosophorus. Increased intracraniel pressure is a result of increase of blood or brain swelling. Metabolic acidosis is associated with a low pH, a normal carbon dioxide level and a low bicarbonate level.

Which is a common anion? • potassium • calcium • magnesium • chloride

Correct response: • chloride Explanation: Chloride is a common anion, which is a negatively charged ion. Magnesium, potassium, and calcium are cations, or positively charged ions.

• A client loses consciousness after strenuous exercise and needs to be admitted to a health care facility. The client is diagnosed with dehydration. The nurse knows that the client needs restoration of: • electrolytes. • nonelectrolytes. • interstitial fluid. • colloid solution.

Correct response: • electrolytes. Explanation: The nurse knows that the client's electrolytes need to be restored. Rehydration after exercise can only be achieved if the electrolytes lost in sweat, as well as the lost water, are replaced. The client does not need to have nonelectrolytes, colloid solution, or interstitial fluid restored. Nonelectrolytes are chemical compounds that remain bound together when dissolved in a solution. Interstitial fluid is the fluid in the tissue space between and around cells. Colloids are substances that do not dissolve into a true solution and do not pass through a semipermeable membrane.

The nurse's morning assessment of a client who has a history of heart failure reveals the presence of 2+ pitting edema in the client's ankles and feet bilaterally. This assessment finding is suggestive of: • hyponatremia. • fluid volume excess. • hypovolemia. • metabolic acidosis.

Correct response: • fluid volume excess. Explanation: Edema is a characteristic sign of fluid volume excess (hypervolemia). Metabolic acidosis is a decrease of the client's pH and increase in the carbon dioxide. Hyponatremia is a low sodium level and not associated with peripheral edema. Hypovolemia is a decrease in blood pressure. Peripheral edema is not consistent with hypovolemia but hypervolemia.

A client age 80 years, who takes diuretics for management of hypertension, informs the nurse that she takes laxatives daily to promote bowel movements. The nurse assesses the client for possible symptoms of: • hypokalemia. • hypothyroidism. • hypoglycemia. • hypocalcemia.

Correct response: • hypokalemia. Explanation: The frequent use of laxatives and diuretics promotes the excretion of potassium and magnesium from the body, increasing the risk for fluid and electrolyte deficits.

Endurance athletes who exercise for long periods of time and consume only water may experience a sodium deficit in their extracellular fluid. This electrolyte imbalance is known as: • hypernatremia. • hypokalemia. • hyponatremia. • hyperkalemia.

Correct response: • hyponatremia. Explanation: Hyponatremia refers to a sodium deficit in the extracellular fluid caused by a loss of sodium or a gain of water. Hypernatremia refers to a surplus of sodium in the ECF. Hypokalemia refers to a potassium deficit in the ECF. Hyperkalemia refers to a potassium surplus in the ECF.

A student nurse is selecting a venipuncture site for an adult client. Which action by the student would cause the nurse to intervene? • asking if the client is right or left handed • palpating the veins on the nondominant hand • placing the tourniquet on the upper arm for 2 minutes • asking the client to pump their fist several times

Correct response: • placing the tourniquet on the upper arm for 2 minutes Explanation: The tourniquet should not be applied for longer than 1 minute, as this allows for stasis of blood that can lead to clotting and also creates prolonged discomfort for the client. Other options are correct techniques when preparing for venipuncture.